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How to Study for the USMLE Step 3

The old adage has been two months for Step 1, two weeks for Step 2, #2 pencil for Step 3. In reality, it’s probably more like two months for Step 1, 1 month for Step 2, and two weeks for Step 3. But if you are worried about getting that competitive cardiology fellowship, it’s hard to nurse the popular opinion that Step 3 is $815 pass/fail two-day pain-fest that you can simply walk in and take. That said, if you comfortably passed Step 1 and Step 2 and it hasn’t been years and years, you will pass Step 3 with nominal preparation outside of familiarizing yourself with the CCS software and the official sample cases. Step 3 is a normalized test, and because all residents put less effort into studying, you simply need to do less work to achieve the same score. I’d recommend taking it during your intern year, because the relatively fresh Step skills and knowledge from Step 2 CK are more important than the clinical acumen you will gain during residency.

Last updated: 12/31/2015

Your resources

A busy intern doesn’t have much time (or desire) to comb through any review book. If you only plan to dedicate 2-4 weeks part-time studying (which is typical), then all you really have time for is USMLEWorld. The question bank itself is around 1567 questions with 51 CCS cases. Forgo the books. Do the UW qbank and definitely do the CCS cases, and you might have time to go through the questions you’ve marked/gotten wrong a second time. Besides, UW now has an iOS app so you can do questions while your attending prattles on rounds. The questions are still hard and the test itself still feels awful, but because everyone studies less for Step 3, you’re likely to perform similarly to Step 1/2CK with only a fraction of the work. (The caveat is that if you struggled to pass Step 1/2CK, then you need to take this test seriously [of course].)

Don’t forget to download the official USMLE Step 3 practice materials here, which contain the official software, some sample questions, and six CCS cases (which are a must do). If you don’t bother going through lots of example cases, at least do the six free cases to become intimate with the software.

If you have the time and desire to do a slow-burn and read actual books, you can (but probably shouldn’t/won’t). However, know that none of entries from the classic series are really as good as their previous Step counterparts.

Crush Step 3 is the fastest, but it’s skeletal and fulls of holes as always. It’s definitely the only book that’s fast enough to blaze through. First Aid was recently updated and likely less out of date; it’s still that densely-packed outline format, which is less high yield and more difficult to get through than it used to be. Master the Boards USMLE Step 3 is probably the best “complete” book on a time and mental energy budget, but there’s still no way most interns will bother getting through it. USMLE Step 3 Triage is more targeted/high yield than First Aid, very readable and well-organized, with a nice conversational tone and a nice free companion website with practice questions [link dead for now] that anyone can use; unfortunately, it was last updated in 2008. You can also find some free questions on the Archer USMLE site.

As always, questions are most important, and UW is indispensable. Never use a book in place of questions. If you’ve spent a few days on a medicine service, an ER, done any general surgery, played with kids, or avoided poisoning a developing fetus, then your clinical experience will serve you well. But you don’t really need it—as always, this is a test. It tests your ability to take a test, not to be a physician.

A few words about the CCS (Computer-based Case Simulations)

Typically getting the diagnosis and the primary treatment are pretty straightforward. The finesse comes from two skills:

Get the diagnosis and management done quickly and efficiently. Do only the focused physical in an emergency. Don’t order and wait for tests that delay proper management. The amount of virtual time that passes prior to certain diagnostic tests or interventions does matter. Don’t just be thorough when “time” doesn’t allow for it.

Know the related but fundamental orders. Using CCS is awkward. You have to order “patient counseling” and other things that you would simply do in real life. You also need to remember to follow up labs and the like. If you start methotrexate, you need to order a follow-up CBC and hepatic function panel. If you diagnose someone with lupus, they need a renal biopsy. If you give someone a stent, they need clopidogrel. If someone is going to surgery, they should be consented. Statins and LFTs. Pregnancy test before giving teratogens to women. Etc. Keep these sorts of things in mind, and you’ll feel much better as you go through the cases.

That said, the little things matter much less than the key management (i.e. appendicitis requires surgery). Like Step 2 CS, you can forget to do a lot of things.

Before you start, it might help you to write out on the test-center sheet the common orders that you would otherwise forget to do so that you can be methodical in your approach (the kinds of things that just happen in the hospital), like starting an IV.

When ordering consults or inputting the primary diagnosis on the final screen, you may ask yourself, “I wonder how this is graded?” Do they have human beings read through more than 25,000 tests to determine if the words deserve credit? Is there an algorithm that checks the text for the presence of the correct words? The answer is neither. This text is not saved as part of the examination, is lost forever in the sands of time, and is in no way used for scoring. Interesting isn’t it? So it makes more sense to use the last two minutes on the final screen of each case to make sure your final orders are as complete as possible rather than making sure you have time to type up the diagnosis.

Recent changes in 2014-15

Being able to take the test on two nonconsecutive days is a good thing, both for scheduling flexibility and for test fatigue.

I see no reason to be overly concerned about the much-maligned “return of basic sciences.” Content changes for the Step exams have remained minimal for quite some time. It’s not as though the addition of “drug ad” style questions has meaningfully changed the prior Step exams or required a significant shift in study patterns. The basic sciences that will be invoked on this test are unlikely to be of sufficient quantity to matter to most takers and are also likely to be the most relevant or highest-yield bits from the old days—the stuff you are most likely to remember anyway. I personally wouldn’t worry too much.

I don’t have any special advice, there aren’t that many of them and they’re pretty straightforward. You just need to be able to figure what the abstracts and ads really mean scientifically about the findings and drugs they discuss. It’s a great vehicle to ask basic stats questions, so you’ll want brush up on your sensitivity, specificity, PPV, NPV, etc. There are a few in the qbanks these days.

Hi, Ben, second question is : If one scores very decent on step 3 , has normal step 1 score, but second attempt on cs and poor step 2 ck score can this step 3 score still somehow magically help him/her during the actual match in internal medicine? Many thanks!

Higher is better, and certainly if it stands out as being higher than the rest it’s not going to hurt. But no PD is actively looking for that, since essentially no US students have taken Step 3. It may be something they’re more used to seeing Step 3 from IMGs, but I wouldn’t even pretend to know what percentage of people have finished it nor what fraction of PDs particularly care.

In this context, the Step narrative is that the person did well on the basic sciences but is probably less versed in US clinical medicine and has potentially poor English/in-person skills. Logically, passing Step 3 handily will dispel at least the CK issue, but it isn’t going to erase the CS failure.

Do you see any potential in a class action lawsuit against USMLE for extortion? i.e. serial examinations created for revenue, not to improve patient care, cough step 2CS, cough cough step 3? How the hell can you justify $815 dollars an examinee?

Sadly, the same complaints would apply not just to the NBME, but to essentially all of the specialty boards as well. Did you know, for example, that radiology residents must pay $625 per year as residents in order to be eligible to then pay for the certification examination which was just split into two tests. This is the nature of non-profit accrediting organizations and probably most organizations in general.

I don’t think any class action lawsuit would be meaningful, though of course many people believe that the effectiveness of the boards on many levels is suspect. The costs are almost irrelevant, as books are easy to balance. I’m sure accounting-wise that it’s very expensive to develop and administer the tests. Besides, the NFL is non-profit but the commissioner made $44 million in 2012.

Regardless, price-gouging is not legally extortion, though it does suck.

Now you’ll be able to schedule the test on nonconsecutive days, which is great because it was often hard for residents to get time off to take the test.

Nonconsecutive days will also help for those who experience test fatigue. If you want to get it over with back to back, that’s still possible too.

The NBME taking over eligibility from the state medical boards will get rid of the arbitrary delays some people had trying to qualify for Step 3. For example, if someone wants to take it at the end of fourth year (say because their residency will be brutal and they have more time to prepare now), then it’ll be much easier/possible to do so.

My guess is that changes in content if any are likely to be minimal, despite a list of topics that includes “applying foundational sciences.” The updated sample questions come out next month, so we’ll see. There will be a (slight?) shift in question-type percentages but probably not any meaningful change in what’s covered. This is probably all for the better.

Hey Ben, Thank you so much for such a comprehensive website! Just wanted to let you know that there are some changes in both the uworld (1567 qns as of now and 51 CCS cases). And, of course the Step 3 price is $815 now. Hope it’s helpful, Sincerely, Y.

The new FA for step 3 seems nice. I read Kaplan Lecture notes and MTB2 and MTB3(for OB and PEDs). I did well on step 2. But honestly I felt MTB was not enough, my scores improved once I read Kaplan lecture notes. I am reading thru FA (2 chapters thus far)and it seems to give a bit more info than MTB…if my memory serves me right. I guess I am trying to ask…what exactly do you not like about FA?

Thanks for the question. I haven’t seen the newest edition yet, it came out just a couple months ago. The high yield facts on the prior were of spotty quality, often extranesouly detailed, and not all high yield. Perhaps more importantly (to me), it’s pretty dense. At that point, in the context of a full time clinical residency position, that wasn’t really a good thing; it just really wasn’t necessary. The CCS portion wasn’t bad but the UW cases are better and more interactive, so what’s the point?

Your point that MTB is incomplete is of course 100% correct. My take is that for most people who are trying to pass, purposefully pruned (high yield) and doable is more important than completeness (completeness doesn’t help if you can’t get through it or retain it, that’s why people use review books in the first place). So FA is fine; it has more detail, so if you’re attempting Step 3 from a maximalist perspective, then absolutely feel free to go for it. Most people I know haven’t managed to really get much out of the books due to time and do just fine with UW (but I’m sure you can find the opposing viewpoint on SDN).

Thank you. Yeah, I see what you are saying. I am not yet in residency…so I may have a little more time to burn through it and perhaps Kaplan Step 3 lecture notes and video for Internal Medicine at least.

I’d personally focus on getting through UW the classic 1.5 times: go through once, flag questions you get wrong or guess on, then do flagged questions again. As you probably don’t have tons of experience writing orders quickly etc, definitely spend time doing all of the CCS cases and exploring the software (while very doable, this is the portion that’s most different from Step 2 CK). That would probably take most/all of the time. If you want to use a book for reference, the new FA might work best given length/detail. If you want to actually read a book, then Crush vs MTB, depending on how much time you want to spend reading.

Hello Ben! Thank you so much as always for your time in writing these marvelous medical school & USMLE strategy articles!! I have used your thoughtfully-written commentary on my recent Step 2ck exam and did much better than expected! Cheers!

I’m officially finished with Step 1/2CK/2CS, and now it’s time for Step 3! However, just like the previous poster has mentioned, I’ll be faced with no formal intern training that many might have when attempting Step 3 (e.g. intern, PGY-1-2-3, physician from another country, etc).

Regarding Step 3 review books (echoing your statements) : What I’ve experienced (e.g. for Step 2ck and now for step 3), is that most of the review books fall short in being able to apply that text-based/factoid-rich information on the actual test day. Out of both purchase popularity and curiosity, I ended up buying copies of Crush, MTB 2CK/3, and the newest First Aid for Step 3. I found them in alignment to what you had said, and question their [review books] utility in answering mcq’s to not be as effective. The books as you stated, might be okay for mental-security reassurances and reference point refreshers. Moreover, the MTB series appears to be tremendously bias in their next step plans/diagnostic tests and at often times, contradictory to what UpToDate and/or Uworld has stated; further adding to stresses that we all can best be without!

Reflecting back to CK, I found that I learned so much better by doing several thousands of practice questions that also had decently written explanations (e.g. Uworld, your post suggestions on each individual MS-3 clerkship question resources).

I was hoping to emulate a similar approach for Step 3 but am finding a limited availability of practice questions/software for both Day 1/2 mcqs + CCS.

I’m subscribed to Uworld Step 3 and their Step 3 CCS component – this undoubtedly will be my foundation as you have stressed, and my intentions are to try my best with understanding all of the MCQ explanations and CCS methodologies.

I’ve previewed some of Archer’s CCS videos but found them to be a bit disjointed… possibly due to the given lack of personal inexperience to how the USMLE is expecting our CCS orders and time advance sequencing to be done.

Do you have any remarks on other “Step 3/CCS practice/teaching software” sources that might be useful as an adjunct? For extra MCQ’s Uworld has questions for the ABIM & Family Medicine Boards but would these be out of scope for Step 3 Day 1/2 mcq’s? The CCS chapter for first aid step 3 was very fragmented without much commentary. Apparently, there’s usmleconsult that offers a step 3 ccs practice software component, but I fear that they haven’t updated content many years and unsure of how their explanations are. There’s also the kaplan qbank and usmleRx questions for Step 3, but I’m equally uncertain as to how those are in similar regards. On amazon, there’s also a printed kaplan Qbook for step 3 but I’ve heard that this might be dated as well.

Appreciate any thoughts for further exploration, and thank you once again for the guidance you have given to all of us! Have a great 2016!

I think UW CCS + the official example CCS cases/software should be sufficient for the CCS portion. The only other dedicated CCS source I know of is via USMLE Consult, as you mentioned, but I don’t know much about their product quality (there is a free trial). I’ve never talked to anyone personally who used either portion of USMLE Consult though old reviews were largely positive (even if it hasn’t been updated recently doesn’t mean it couldn’t be helpful, but UW cases are probably enough).

The key is to become familiar with the software, which you will definitely be able to do via the UW + official volume. While you won’t have seen every possible case scenario, you will have seen enough to “work-up” a problem de novo. Archer may be more helpful after you’ve done some practice cases.

For more MCQ questions, choices are USMLERx, Kaplan, USMLEConsult, and BoardVitals (the company that offers the bulk of speciality board qbanks). I haven’t done any of them so sadly can’t really comment on the best of them (I’d like to trial them all out and comparison review them but it’s not super high on the todo list). I’m not endorsing BoardVitals, but they do have a referral program, so if you do plan on checking them out, that link is an affiliate link and you can save 10% using code BW10 at checkout.

Hi Ben, I read your blog entry while I was in the US waiting for interviews. I am now in my home country where I am currently practising and waiting for match results. I plan to take the step 3 this last week of april or 1st week of may. I was initially just considering uw + ccs. I have around 8 weeks to review. You think I can still squeeze in the MTB step 3? How long would doing UW + ccs alone vs doing it plus MTB take on the average? Any significant impact on passing or getting a better score, if I do just UW + CCS vs adding MTB? Regards

You can probably squeeze in MTB just fine. How long depends on how much time per day you have. I’d say UW+CCS would take 4-5 weeks full time for the thorough treatment but can certainly get through it faster if necessary. Add a week for a review book. I doubt MTB will add that much unless it’s been a long time since Step 2 CK or other similar review. If you feel rusty and uncomfortable not having a fresh foundation, a quick read of MTB would be a reasonable place to start prior to UW.

Hi Ben, I failed Step 3 multiple times with a borderline to low performance on my MCQs and a borderline to above borderline performance on my CCS. Ive done UW Step 3 several times as well as Kaplan and I feel it is not helping. Would you recommend I do UW Step 2 to refresh my Step 2 CK knowledge as my Step 2 CK score was also low but passed on first attempt. There is correlation between Step 2 and Step 3 scores Im guessing? Please let me know. Thanks!

There’s a strong correlation between all Step scores, but I suspect this has more to do with the person taking the exam and not precisely because of overlap, though Step 2 CK definitely does have overlap with Step 3.

I guess the big question is when you look at your qbank performance, what are you getting wrong? I’d venture I’d prefer to try a third qbank source like Rx or Board Vitals (the latter which offers a 10% discount with code BW10, for what it’s worth) than to go back to an earlier UW if you feel like you’re spinning your wheels. That said, if you’re getting diagnoses wrong, your idea may have merit. If it’s management, next step, etc, then a new qbank is probably a better use of time.

I haven’t read them and they’re certainly not crucial, but if you like the books then why not? Just like Step 2 and the Medicine shelf, medicine makes up a lot of Step 3. Just do some questions so you won’t miss out on the points for ob/gyn, surgery, and EM style stuff.

You mentioned that you say it is primarily test-taking. I’d beg to differ. It becomes primarily test-taking because all of our medical schools do a horrible job teaching us the material that the Boards requires everyone to know and foreign medical grads learn it better overseas and have to write programs like USMLE World to teach the material properly to us all. Meanwhile the med schools rob every student with their inferior education and crappy teachings. The Board exams are not primarily about test-taking. It is a sign that you don’t know the material, never learned it, and simply guessed your way through the USMLE’s to be a doctor, without ever really learning medicine. Bravo, another doctor practicing who doesn’t know his or her field.

I agree that medical schools are expensive and don’t necessarily provide a great education. I don’t really understand how it follows that pointing out that a written multiple choice exam is not the same thing as practicing medicine means that someone doesn’t understand medicine or “know his or her field.”

Hey there, very informative. I’m worried about step 3 as I’m an IMG with poor scores on steps 1 and 2. I will be starting OB/GYN residency next year so I’m especially worried as my work will overlap with little of what’s on the exam. I have time now as a 4th year. What book/videos could help now before doing the UW questions during intern year? Would you recommend I restudy Step 1 or 2 CK materials?

Definitely don’t redo anything from Step 1. Some people have mentioned redoing UW Step 2CK. There’s plenty of overlap there but I don’t think that’s necessarily a great idea, because the focus is a bit off. A deep dive of UW is more than most people ever have time for, so you could buy the year and then do it now, then reset and redo later. Mark the ones you guess on or get wrong, then do those again. For books, I’d probably read Crush first, then MTB since you have time.

I love your tips and website has helped me excel throughout MS-3 and 4. I do have a dilemma. I am a chronic worryier and find myself getting anxious for step 3. Partly because Idk when I will be able to take it given process of being able to register for the test. Last day of med school is April 21st, but diploma is may 12th. Anyways I digress. I matched in pediatrics and some residents tell me to the point of putting the fear of god in to take before residency. However that may not be possible. Secondly, I learn better from on job training when it comes to managing patients. Since the step 3 tests your ability to function without supervision I am scared to take it because I need supervision at this point in my career. My step 1 was 226 2ck 235. I am afraid of forgetting everything IM by waiting, but battle myself with knowledge majority of test takers are interns, peds surg IM OB psych all the same and they do well.

What I am really asking is how would you proceed? Do you know other peds interns that were in my shoes? How did they do? What did they do? Thank you for any insight you can give me.

Step 3 is most like Step 2 CK coupled with a computerized version of Step 2 CS. The management portions really aren’t anything that requires real life experience to do, and the content is basically the same as Step 2 with a few fewer zebras. It doesn’t really matter what residency you do because you could pass it with or without clinical experience. Waiting a few months won’t matter, but I wouldn’t, for example, wait until the end of residency. Almost everyone I know personally (peds included) took it during intern year. Having some time in the evenings to practice with the CCS software is really the main consideration for taking it during residency.

Good amont of information. i will certainly have doubts to ask when i give step3. But i still want to ask you something. i appeared step 1 in 2011 and this is my second chance since i have failed in first. How are my chances ahead.

I believe that the biggest predictor of failure is prior test failure. And Step 1 is the most commonly failed out of the four exams. The question is if enough has changed from the first attempt to now, which only you know. It’s also important to make sure your English will be good enough to pass Step 2 CS.

Thanks for sharing all of the great info on your website! My question is in regards to any specific advice of anything else to do to try and beat the average for Step 3? I’m a recent US Allo Grad and passed both Step 1 and 2 CK on first attempt, but only by 10 points higher than the passing score (on both). I just started residency (IM wards) but need to take Step 3 early (by end of August – I signed up for dates in early and mid August) for certain reasons and need to do as well as possible. I just started UWorld and tried to read Crush, but am finding that I don’t really like Crush 3 – too many holes and seems like randomly jumping from topic to topic with random facts. I’m a big overview person, so the method now is to review Emma Holliday first, do UWorld, and hopefully some OnlineMedEd bc I feel like I forgot a lot, even though I’m doing pretty well on UWorld so far. Do you have any other tips? Technically, I feel like I should read something bc I feel like my Step scores are low bc of little gaps in knowledge from first and second year, but I don’t know if I can totally reconcile that in 6 weeks, since I’m on IM wards now. And I find that I learn better with tons of qs, one big overview material like Emma or OnlineMedEd and a short and concise book but time is of the essence now. Any specific tips? Thanks again!

I don’t have any specific resource advice to offer outside of that I’d find it very difficult to get much more than UW done in 6 weeks while working as a medicine intern. You might like MTB if you don’t like Crush, but as you said, you can probably only squeeze one thing (at least partially) in on the side, so just pick whichever you find the least boring.

Don’t forget to give the CCS cases a serious effort in the final few days especially.

Hi Ben, Thank you for tips and plans for step 3. I have about 7 weeks to study for step 3. I’m planning to use Kaplan Qbank (900 q’s) to supplement my MTB reading and also UWorld (1500 q’s). How would you approach it if you were in a similar situation? Should I read MTB during the first week? and then start kaplan qbank? Do 80 questions (a block of Uworld and Kaplan Qbank daily to mix things up) daily? I’ve used solely Uworld for step 3 first time around during my intern year and it didn’t go so well. So, I want to use my time wisely this time, considering I’m dedicating 7 weeks alone to study. Also, one of my weakest areas is biostats and I need to fit the review in there somewhere.

Hi Ben! I used your Step 1 and 2 explanations posts when studying for the boards in medical school. Now I’m an intern taking Step 3 in a few weeks. I was wondering if you have any official Explanation posts for the Step 3 sample questions? I like your thought process. Thank you!